Ultrasound-guided stellate ganglion blockade: an appealing tactic for cardiac electrical storm

V entricular arrhythmia (VA) is a life-threatening cardiac emergency.When VA occurs three times or more within 24 h and interventions are required, it is defined as an electrical storm (ES) characterized by refractoriness and recurrence. [1]For patients with implantable cardioverter defibrillator (ICD), the notion is redefined as no fewer than three appropriate and separate (at least 5 min for each interval) ICD interventions given within 24 h.ES often leads to poor quality of life and high rates of hospitalization and mortality. [2,3]The acknowledged pathogenesis involves complex interactions among triggers, cardiac substrates, and autonomic vulnerability.Triggered behaviors predispose patients to ES, whereas cardiac substrate maintains ES. [4] Cardiac disorders may cause structural and electrical remodeling of heterogenic myocytes, which could lead to functional reentry and an increase in the incidence of ES. [5,6] Sympatho-excitation plays a crucial role in ES genesis.Researchers found an elevated sympathetic tone induces arrhythmogenic changes as well as sizable reduction in heart rate variability prior to the onset of ventricular tachycardia (VT) in canines. [7,8]nother pathologic aspect is sympathetic alteration in form of hyperinnervation. [9]Recently, stellate ganglion (SG) in the autonomic nervous system is recognized as a crucial role among the pathophysiological mechanism.To stabilize patients' hemodynamics during acute management, advanced cardiac life support and external defibrillation may be required.When necessary, sedation and intubation are added.There is evi-dence that two ICD therapy modalities introduced during ES increase mortality for those who have ICD installation as palliative prevention. [10]-blockers and other antiarrhythmic drugs are mainstay for treatment.-blockers are the first-line pharmacologic therapy advised for ES management, among which nonselective -blockers exert better antiarrhythmic efforts. [1,11]Nademanee, et al. [12] discovered that patients who underwent -blockade had a remarkably greater survival rate than those who received conservative antiarrhythmic therapy.However, the efficacy of -blockers is less systematically specific and limited by side effects like drugs intolerance.Patients afflicted with acute heart failure, end-stage organ failure, or pulmonary edema are not amenable to -blockers.Cardiac sympathetic denervation (CSD) permanently suppresses sympathetic main flow to the heart.Two systematic reviews reported it freed near or more than 60% of patients from VT events in the postoperative period. [13,14]Recent studies have suggested that CSD may provide a moderately additional mid-to long-term benefit before or after catheter ablation (CA). [15,16]Even though CA and CSD proved to be effective, they are not always carried out as intended.Hemodynamically compromised or critically ill sufferers hardly tolerate surgeries and transportation to operating rooms.Besides, CSD is unavailable in many basic medical institutions and CA is frequently inaccessible.According to a survey by the European Heart Rhythm Association, only 16.5% of affiliated hospitals offer CA around the clock. [17]he inferior cervical ganglion and the first thoracic